ED Coding and Reimbursement Alert

Legitimate opportunities for increased ethical revenue are being lost if emergency department coders don't recognize when they may report burn treatment services provided by physicians, according to Kenneth De Hart, MD, FACEP, president of Carolina Health Specialists in Myrtle Beach, S.C. "Based on my experience, there are many emergency departments in many parts of the country that fail to recognize when the 16000-16030 series may be invoked and, therefore, these codes are vastly underutilized," he says.
 
Instead, coders often assign only emergency visit codes (99281-99285) to report burn treatment, resulting in lower payments. For example, the fully implemented facility total relative value units (RVUs) for a level-three ED code (99283), according to the 2002 Physician Fee Schedule, is 1.60. On the other hand, the RVU for 16025* (dressings and/or debridement, initial or subsequent; without anesthesia, medium [e.g., whole face or whole extremity]) is 2.70.
 
The codes from the burn series most often used in an emergency department are 16000 (initial treatment, first degree burn, when no more than local treatment is required), 16020* (dressings and/or debridement, initial or subsequent; without anesthesia, office or hospital, small), 16025* and 16030 ( without anesthesia, large [e.g., more than one extremity]). Other codes in the series require the use of anesthesia and, most often, other specialists would be called to handle cases of this nature.
 
According to Tracie Christian, CPC, CCS-P, director of coding for ProCode in Dallas, 16000 is being used now more than it was in the past. "Not too long ago, this code could not be reported when only dressings were applied to a burn. The code description was changed, however, to read 'dressing and/or debridement.' This allows us to appropriately report this code more frequently," she says.
 
Note: Burn treatment codes are reported only when the physician personally provides the service. If the physician simply assesses the burn and a nurse dresses it, only an E/M code may be reported for the assessment.

When determining whether a burn is small, medium or large, apply the Rule of Nines. Charts demonstrating how this concept applies to both an adult's and a child's body can be found in the CPT manual adjacent to the 16000 code series. The rule allows physicians and coders to calculate the total body surface area (TBSA) affected by the burn by dividing the body into 9 percent increments. Three adult body areas are considered to each equal 9 percent the head and neck, the right arm, and the left arm. The back trunk, front truck, left leg and right leg are each considered to equal 18 percent. The perineum equals 1 percent TBSA. The front and back trunk, and each leg, may be divided into upper and lower segments, with each component totaling 9 percent.
 
Burns that encompass less than one-half of any body segment (i.e., 4.5 percent) constitute a small burn, while a medium burn covers is anywhere from half to a whole body segment (4.5 to 9 percent), and a large burn is greater than 9 percent.

In addition to the burn codes, there are occasions when an ED visit code may also be correctly assigned, DeHart says. "It's imperative that coders consider the basic tenants of a distinct and separately identifiable E/M service," he says. "When these requirements are met, both the burn care and the E/M service may be reported, with modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) appended to the E/M code." Codes 16020 and 16025 are starred procedures and, therefore, modifier -25 would not be needed when an E/M service is provided in conjunction with either.
 
Although no clear guidelines regulate when an E/M service is distinct, DeHart illustrates when both codes might be reported. "Perhaps a patient was carrying a pot of boiling water, slipped, fell and hit her head, and burned herself. The ED physician will not only treat the burn but will also evaluate the patient for a skeletal and head injury. This level of service may constitute an E/M service in addition to the burn treatment," he says.

Three Diagnosis Codes Often Required

Diagnosis coding is equally important when reporting burn services, Christian says. "The ICD-9 manual does a terrific job of outlining the proper diagnosis codes. Coders must be certain to choose the code that most specifically describes the condition." Usually at least two, and often three, diagnosis codes are assigned when burns are treated.
 
The primary diagnosis code is chosen based on the location and severity of the burns being treated. These codes may be found within the 940-947 section of the ICD-9 manual, Christian explains. All the codes in this series require at least a fourth and sometimes a fifth digit. The first three digits describe the general body area that is affected. Code 942 refers to burn of trunk, for instance, while 947 describes burn of internal organs.
 
Beyond the decimal point, the fourth digit indicates the severity of the burn, classifying the burn in one of six categories from least to most severe. In the 941 category (burn of face, head, and neck), for instance, the following scale applies:

941.0 unspecified degree

941.1 erythema (first degree)

941.2 blisters, epidermal loss (second degree)

941.3 full-thickness skin loss (third degree, NOS)

941.4 deep necrosis of underlying tissues (deep third degree) without mention of loss of a body part

941.5 deep necrosis of underlying tissue (deep third degree) with loss of a body part.

Coders should choose the fourth digit based on the most severe level of burn documented in the patient record. For instance, if the patient suffered both second- and third-degree burns on her leg, 945.3 (burn of lower limb[s]; full-thickness skin loss [third degree NOS]) would be chosen.
 
Further, the fifth digit specifies the exact location of the body part affected. Within the 945 category for burns of the lower limbs, for instance, the following fifth-digit definitions are provided:
 
0 lower limb (leg), unspecified site
1 toe(s) (nail)
2 foot
3 ankle
4 lower leg
5 knee
6 thigh (any part)
9 multiple sites of lower limbs.

A similar chart outlining the fifth-digit classification is beneath the code description for each body part. Therefore, if a patient suffered a second-degree burn on the back of her hand, the appropriate diagnosis code would be 944.26 (burn of wrist[s] and hand[s]; blisters, epidermal loss [second degree]; back of hand). Similarly, if a patient presented with third-degree burns over a large portion of her face, 941.39 (burn of face, head, and neck; full thickness skin loss [third degree NOS]; multiple sites [except with eye] of face, head, and neck) should be used.

The second diagnosis code that must be reported with burn codes is 948.xx (burns classified to extent of body surface involved). Rather than telling payers what part of the body is injured, this code describes the severity of the burn. On the surface, this code appears complicated because its intent to is relay two sets of information about the burn. Code 948 requires both a fourth and fifth digit, with each digit describing a different type of burn. The fourth digit details the total percentage of the body that has been burned, while the fifth digit indicates the percentage of the body affected by third-degree burns.
 
For example, if a case is coded with 948.21, the fourth digit (2) indicates that 20-29 percent of the body surface has been burned. The fifth digit (1) indicates that 10-19 percent of the body surface involves third-degree burns. To assist coders, the ICD-9 manual indicates which fifth digit may be reported with each fourth digit with brackets under the four-digit code description.
 
DeHart notes that, to assign the proper codes, ED physicians must be careful to document the percentage of body burned, the body parts affected and the severity of the burns. "If this sort of clinical information is not provided in the record, it is impossible for the claim to be coded correctly," he says.

Most burn cases require an E code to present the exact cause of the burn. An E code is always a tertiary code and may help the payer determine if a third party may be partially liable for the costs of treatment, e.g., if the burn occurred at the workplace, workers compensation may be billed. With the patient who dropped a pot of boiling water, for instance, E924.0 (accident caused by hot substance or object, caustic or corrosive material, and steam; hot liquids and vapors, including steam) would be assigned. Coders should recognize, however, that not all payers recognize E codes, and specific payer requirements must be followed.